Common Contracts
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Agreement to Carry and Self-Administer MedicationIllinois • June 3rd, 2019
Student Name: Birth Date: Address: Parent/Guardian Phone: Emergency Phone: School: Grade: Teacher: Physician Name: Physician Phone: Medication: Inhaler Epinephrine The items below must also be provided: □ Prescription label, which contains the name of the medication, the prescribed dosage, and the time at which or circumstances under which the medications is to be administered. (Attach to this form) □ For Epinephrine: Medication Authorization Form and Emergency Action Plan ***It is recommended that students who carry and self-administer medication keep “back-up” medication at school.
